Dietary Patterns in Toddlers with Excess Weight. the 2016 Pitnuts Study

Abstract Introduction Children’s appropriate dietary pattern determines their optimal development, reduces the risk of childhood diseases and the risk of diet-dependent diseases, including obesity in adulthood. Aim To analyze the dietary patterns of children with excess weight aged 1-3 years in comparison with the main components of the safe nutrition model including: the organization of meals (frequency of meals), selection of products (food intake), energy and nutritional value of children’s diets. Material and methods The study was carried out in 2016 on a representative nationwide sample of children aged 5-36 months (n=1059). The analysis of dietary patterns covered 173 with excess weight children aged 13-36 months (BMI-z-score >1 SD). Their nutritional status was evaluated based on BMI and its standardisation according to the WHO reference child growth standards for children aged 0-5 years (BMI z-score). The diets of children were assessed using 3-day dietary records. The dietary patterns of the children who were analysed were determined using the cluster analysis (k-means method), including 11 variables concerning average daily intake of main food group products (cow’s milk, junior formula, milk products, bread, groats and rice, cereals, cured meats, fats, sugar and sweets, fruits, nectars and juices). Results Three clusters of overweight and obese children with different dietary patterns were identified. The diet of children from the first cluster (n=58) was based primarily on junior formula and foods for infants and toddlers. This dietary pattern was defined as the “baby food diet”. The second cluster comprised 33 children whose diets were characterised by high consumption of cow’s milk and dairy products, as well as cereal products, including bread, groats, rice and breakfast cereals. This dietary pattern was defined the “milk and cereals diet”. The third cluster consisted of 82 children whose dietary pattern was characterised by high consumption of bread, cold meats and fats, sweets, juices and fruits (the “sandwich and sugar diet”). In all the clusters the average intake of vegetables and fruit by children with excess weight was significantly lower than the recommended amounts. The study showed too high intake of energy, protein, sodium, B vitamins and saccharose and an insufficient supply of calcium, fibre, vitamin D, vitamin E, LCPUFA, iodine and potassium in the children’s diet in reference to nutritional recommendations. Younger children with the “baby food diet” pattern, due to the contribution of enriched food, had a more balanced diet in relation to the model of safe nutrition (nutritional norms). Older children’s diets – in the third year of life, were characterized by a diversified choice of products that are a source of protein and carbohydrates (milk, breakfast cereals, meat, bread, cold meats, sugar from beverages, dairy desserts and juices). Conclusion The identified dietary patterns of toddlers with excess weight differ from the safe nutrition model in terms of product selection and nutrient profile.

INTRODUCTION Appropriate diet determines a child's its optimal development, reduces the risk of childhood and dietdependent diseases, including obesity in adulthood [1][2][3][4]. In recent years, research proved that childhood obesity re ects interactions of genetic and environmental factors, including dietary ones, and that excessive weight in toddlers is a predictor of obesity at preschool and school age [1,[5][6][7]. It also increases the risk of chronic non-infectious diseases, such as type 2 diabetes or cardiovascular diseases. In obesity prevention, the basis for an appropriate diet is provided by safe nutrition models for toddlers, including recommendations for nutritional practices, choice of food in the diet, as well as nutrient pro les compliant with the standards [8,9]. erefore, dietary patterns of children, de ned by the consumption of foods from various product groups and nutrient pro les, should be similar to the recommendations of the safe nutrition model.

AIM
To analyse the dietary patterns of with excess weight children aged 1-3 years in comparison with the main components of the safe nutrition model including organization of meals (frequency of meals), selection of products (food intake), energy and nutritional value of children's diets.

MATERIAL AND METHODS
e PITNUTS study was carried out in 2016 on a representative nationwide sample of children aged 5-36 months (n=1059). e analysis of dietary patterns covered 173 overweight and obese children aged 13-36 months (BMI-z-score>1SD and more). eir nutritional status was evaluated based on measurements of body weight and height, calculation of their BMI and its standardisation according to the WHO reference child growth standards for children aged 0-5 years (BMI z-score) in line with the applicable methodology [10]. e diets were assessed using 3-day dietary records of children prepared by their parents. e records were used for the estimation of daily food rations (food consumption) and the nutritional value of the rations was calculated using the Dieta 5.0 nutritional programme [11][12][13]. e data from the questionnaire on environmental and family conditions of the children who were analysed were also taken into account. e dietary patterns of the children with excess weight analysed were determined using the cluster analysis (k-means method), incorporating 11 variables on average daily consumption of milk and dairy products (including cow's milk, follow-up formula and fermented milk beverages), cereal products (bread, groats and rice, breakfast cereals), as well as fruits, cold meats, fats, sugar and sweets, nectars and juices.
In the clusters of children with various dietary patterns that were obtained, di erences were analysed in terms of environmental variables (parents' education, place of residence, socio-economic status and parents' BMI) and nutritional variables (meeting dietary standards for energy, macronutrients, calcium and vitamin D, nutritional practices and consumption of recommended food rations, i.e. appropriate consumption of products from various food groups). e statistical analysis of the results obtained was performed using the Statistica 12 PL statistical package. e analyses were performed using the chi-square test (variables on a nominal scale) and the Kruskal-Wallis Anova rank test (variables on an ordinal or higher scale). e statistical signi cance level of p<0.05 was adopted.

RESULTS
e cluster analysis using the k-means method made it possible to distinguish three clusters of children with di erent dietary patterns. e rst cluster comprised 58 children in the second year of life (age median 19.9 months). e other two clusters included children in the third year of life (age median: 26.0 and 26.6 months). e diet of the children from the rst cluster (n=58) was based primarily on junior formula and ready-to-serve foods for infants and toddlers. is dietary pattern was de ned as the "baby food diet". e second cluster comprised 33 children whose diets were characterised by a substantial share of cow's milk and dairy products, as well as cereal products, including bread, groats, rice and breakfast cereals. e children from that group also ate a lot of cold meats and products containig sugar, including sweets. is dietary pattern was de ned as the "milk and cereals diet". e third cluster consisted of 82 children whose dietary pattern was characterised by high consumption of bread, cold meats and fats, as well as a signi cant amount of products being a source of simple sugars and disaccharides (sweets, juices, fruit). e consumption of cow's milk was reduced and partly replaced by sweet dairy products, including fruit yoghurts and milk desserts. e dietary pattern of the children from that cluster was de ned as the "sandwich and sugar diet". Table I presents the characteristics of children in individual clusters in terms of their family background. Statistically signi cant di erences in the parents' education of the children from the analysed clusters were found (mothers p=0.09, fathers p=0.02). e parents of the children from the second cluster were the least educated. e analysed groups of children did not vary in terms of place of residence or subjective assessment of their nancial situation. e BMIs of the parents of children from various clusters did not show statistically signi cant di erences, either. Table II presents the comparison of average daily food rations of children with di erent dietary patterns with respect to the recommended food ration for children aged 13-36 months [9]. e identi ed dietary patterns of children with excess weight were not compliant with the recommended daily food rations. Almost every child from the second and third cluster ate over twice as much bread and several times more meat and meat products as compared to the recommended daily food ration. e consumption of pasta and potatoes exceeding recommendations was observed in the diets of more than 30% of the children. About 50% of the subjects ate too many dairy products (cheese), eggs and fats. e quantity of sugar and sweets in the diets of 48.3-78.9% of the children exceeded daily limits. e odds of the children not following the sugar and sweet consumption limitations is increasing with the children's age. e average intake of vegetables and fruits in all the clusters of children with excess weight was signi cantly lower than the recommended amounts.
Table III presents the energy and nutritional value of the identi ed dietary patterns of the children analysed in comparison with dietary standards [11]. e majority of diets of the children (in all clusters) exceeded the EAR standard for protein (100% of children) and digestible carbohydrates (86.2% children in the rst cluster, 97.0% children in the second cluster, 87.8% children in the third cluster). A higher than recommended share of energy from saccharose was identi ed in the diets of 63.8-79.3% of the subjects. e ful lment of the requirement for energy (EER) and fat (EAR) in the diets of children with di erent dietary patterns varied signi cantly. In the second cluster ("milk and cereals diet") 93.9% of the toddlers exceeded the           requirement for energy (compared to 58.6% in the rst cluster and 65.6% in the third cluster), 75.8% exceeded the requirement for fat (compared to 36.2% in the rst cluster and 51.2% in the third cluster). Children from the second cluster did not ful l the requirement for dietary bre with signi cantly higher frequency than children from other clusters. e diets of the majority of the children did not have any iron de ciencies or any de ciency of phosphorus, magnesium, zinc, copper and vitamin A, vitamins from the B group and vitamin C.
Nutrient pro les of the diets of children from all clusters exhibited signi cant de ciencies of LCPUFA and vitamin D. A de ciency of vitamin E was found in 72.7% and 75.6% of the children (cluster two and three), and potassium de ciency was observed in all the clusters (81.7-96.6%). e requirement for calcium was ful lled in 97.0% of the children in the second cluster, in 70.7% -in the rst cluster and 40.2% of the children in the third cluster. Calcium de ciency was observed in 29.3% and 59.8% of the children ( rst and third cluster, respectively). Iodine intake was lower than the recommended level in 18.2% of the children from the second cluster and in 31.7% of the children from the third cluster.
Excessive sodium intake was found in the diets of all the children from the second and third cluster and in 85% of the children from the rst cluster.
Nutritional practices in all the children analysed di er from the safe nutrition model -79.3-89.0% of the children received snacks between meals every day or at least 2-4 times a week, had meals before bedtime (69.7% in the second cluster, 56.9% in the rst cluster and 48.8% in the third cluster; p=0.06) and ate or drank during night time (46.3% in the third cluster, 39.4% in the second cluster and 37.9% in the rst cluster; p=0.03). Children from the rst cluster signi cantly more frequently received foodstu s intended for infants and toddlers (junior formula, baby cereals and gruels) (p<0.05). e odds of breastfed toddlers were signi cantly higher in the third cluster (p=0.005) (Table IV ).   patterns of children in infancy had an impact on their diet and risk of obesity at preschool age [14]. Infants whose diet was higher in fruit and vegetables at 9 months had higher fruit and vegetable intake also at 6 years of age. Similarly, infants with a dietary pattern characterized by foods high in energy density (French fries, sweet desserts) continued to have higher consumption of these foods at 6 years old, and had a higher prevalence of overweight (43%). Formula-fed infants had higher sugar-sweetened beverage intake and fewer fruit and vegetable intake at 6 years than breastfed infants. Another study which aimed at identifying the dietary patterns of infants in the rst year of life showed that the main determinants of their variability were not only the mother's education and age, but also the place of residence [15]. Our results con rm the in uence of the educational level of not only the mothers, but of both parents, on the dietary patterns of children in post-infancy. e results of many studies proved that widespread prevalence of excess body weight even in the early period of life is correlated with the intake of food with high energy density [2,3,7,16].
It is supposed that lower quality diets, high in energydense, high-fat products and low in dietary bre consumed in childhood and adolescence are associated with the risk of obesity, as they undermine innate appetite control, which may lead to greater energy consumption [17]. Such a dietary pattern was found in overweight and obese children in the third year of life (cluster 2 and 3).
Inappropriate food choices and portion sizes and a diet which is well-balanced in terms of nutrient pro le may be related with an increased risk of obesity [18][19][20].  In the study conducted the most frequently used food products were identi ed in the diets of children with excess weight. In toddlers in their second year of life (cluster 1) the main products were foods for special nutritional purposes, intended for young children, such as junior formula, baby cereals and gruels. In children in the third year of life (cluster 2 and 3) the diet base was cow's milk, breakfast cereals, groats and bread. All the overweight and obese children consumed excessive quantities of meat and meat products, as well as foods being sources of sugar (dairy desserts, sweet beverages and juices).

AddiƟonal meals
Research conducted in recent years indicates that food choices following the safe nutrition model guidelines ensure the proper energy and nutritional value of a child's diet and decrease the risk of developing eating disorders and obesity [7,[21][22][23].
e assessment of diets of children residing in di erent countries, including the European Union, showed that excessive energy and nutrient intake (i.e. excess of protein) is a risk factor for developing childhood obesity [2,24]. It was also found that the adequate intake of macronutrients, calcium, bre, vitamin D is negatively correlated with the risk of childhood obesity. On the contrary, the increased intake of B vitamins (B1, B2, niacin, which may enhance fat synthesis), excessive consumption of sweet beverages being sources of mono-and disaccharides contribute to developing obesity [7]. In our study we observed an excessive intake of energy, protein, sodium, B vitamins and saccharose and an insu cient supply of calcium, bre, vitamin D, vitamin E, LCPUFA, iodine and potassium in children's diet in reference to nutritional recommendations. e analysis of nutrient pro les in the diets of the overweight children pointed to the need to popularise the model of food rations among the parents of young children.
CONCLUSIONS e identi ed dietary patterns of overweight toddlers di er from the safe nutrition model in terms of product selection and nutrient pro le.
Younger children with excess weight, with separate dietary patterns, require fast nutritional intervention to introduce proper food choices in their diets.
Nutritional education is required for parents or caregivers of overweight toddlers, with a particular focus on the group with a signi cantly lower level of education.